Howraman MeteranMD, Ph.D, postdoc

Respiratory Research Unit Bispebjerg University Hospital

GINA Guidelines update 2018

Hotel Bella Sky

Respiratory Research Unit, Bispebjerg University Hospital

Disclosure

Advisory board for ALK-Abelló Nordic A/S

Dept of respiratory Medicine, Bispebjerg Hospital

Updates within several areas

• Risk factors for exacerbations

• FeNO

• Steps in treatment

• Asthma-COPD overlap

• Asthma in special populations

• Follow-up after acute asthma

• Asthma treatment in preschool children

• Prevention of asthma

Assessment of asthma

• Focus on two domains• Symptom control• Future risk of adverse outcome, treatment issues and

comorbidities

• Identified risk factors for future exacerbations are independentof symptom control

• Lung function is the most useful indicator of future risk and should be recorded as diagnosis, 3-6 months after starting treatment and periodically thereafter

Asthma symptom control

Characterics YesNoControlled Partly

controlled Uncontrolled

Daytimesymptoms>2perweek?

Noneofthese1– 2

ofthese3-4ofthese

Nightwakingduetoasthma?

Reliever needed >2perweek?*

Anyactivity limitations duetoasthma?

*Excludes reliever taken before exercise

Assessment of asthma in children 6-11 years

• Asthma symptom controlExample, level of activity (LoA):- What sports/hobbies/interests does the child have, home,

school, spare time? - LoA compared with friends and siblings?- Get an accurate picutre without interruption from the parent

• Future risk factors

• Treatment factors

• Comorbitidies

• Other investigations if needed (e.g. 14-days diary)

For more, see Box 2-3, page 30.

Asthma Control Test (ACT)

ranges from 5-25 and minimum clinically difference is 3 points

GINA 2014:Well-controlled: 20-25Not well-controlled: 16-20Very poorly controlled: 5-15

GINA 2018:Well-controlled: 20-25Not well-controlled: 16-29Very poorly controlled: 5-15

What does asthma control mean?

• Discordance between patient’s and health provider’sassessment of the patient’s level of asthma control

• Patients do not neccessarily over – or underestimate their level of control. They understand ”control” differently from the health providers

• Examples of how to describe asthma control:

• Karl-Johan has good asthma symptom control, but he is at increased risk of future exacerbations because he has had a severe exacerbation with the last year

• Yvonne has poor asthma symptom control. She also has several additional risk factors for future exacerbations including low lung function, current smoking and poor medication adherence

Risk factors for future exacerbations

• High SABA use (more than 1 x 200 cannister/month)

• Inadequate ICS (not prescribed, poor adherence, inhaler tech.)

• LOW FEV1, specially if <60% predicted

• Major psychological or socioeconomic problems

• Exposures: smoking, allergens if sensitized

• Comorbidities: obesity, CRS, confirmed food allergy

• Eosinophilia

• Ever intubated in ICU for asthma

• 1 or more severe exacerbation in the last 12 months

• Higher bronchodilator reversibility

• Elevated FeNO (in adults with allergic asthma taking ICS)

Risk factors for developing fixed airflow limitation

• Lack of ICS treatment

• Exposures: tobacco smoke, noxious chemicals, occupationalexposures

• Low initial FEV1, CMH, eosinophilia

• Preterm birth, low birth weight and greater infant weightgain

The use of FeNO

• FeNO has not been established as useful for ruling in or ruling or a diagnosis of asthma

• FeNO > 50 is associated with a good short-term response to ICS• FeNO cannot be recommended at present for deciding against

treatment with ICS

• FeNO – and ACQ-guided treatment in pregnant women was better than ACQ-only to significantly reduce exacerbations and improve fetal outcomes

• FeNO-guided treatment significantly reduces exacerbation rates compared with guideline-based treatment (in children and young adults)

• In preschool children, FeNO predicts PD-asthma at school age, increased risk of wheeze and ICS uge at school age

GINA step 5

Anti-IgE (omalizumab): patients from age 6 with moderate or severe allergic asthma

Anti-IL-5 (mepolizumab) patients from age 12

Anti-IL-5 (reslizumab), intravenous in patients from age 18

Anti-IL-5R (benralizumab), subcutaneous in patients from age 12 with severeeosinophilic asthma

Asthma-COPD overlap

Recommendations for initial treatment in patients with ACO

With asthma featuresICS, not LABA as monotherapy

With COPDbronchodilators or combination (ICS/bronchodil), but not ICS as monotherapy

ACOlow or moderate ICS. Add-on with LABA and/or LAMA is usually also neccessary.

Asthma in special populations

Perimenstrual asthma (catamenial asthma)

In 20% of women, asthma is worse in the premenstrual phase.

They are older have severe asthmahigher BMIa longer duration of asthma greater likelood of aspirin exacerbated respiratory diseasemore often dysmenorrhea (pain)premenstrual syndromeshorter menstrual cycleslonger menstrual bleeding

Primary prevention of asthma

Children should not be exposed to tobacco smoke during pregnancy or after birth

Vaginal birth should be encouraged where possible

Breast-feeding is advised

The use of broad-spectrum antibiotics during first year of life should be avoided

Short points from the report

Allergic rhinitis: treatment with NCS is associated with improved asthma outcome only in patients without ICS

Follow-up after acute asthma presentation: Patients should be instructed to take their reliever only when needed rather than regularly

In preschool children: blood eosinophils and atopy predicts greater short-term response to moderate ICS than to LTRA

Never stop breathing!